Sample Student Health Record Form
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1
2HEALTH RECORD FORM
All students are required to file a current health record with Lipscomb University Health Services at the time of enrollment. This information is confidential.
All sections must be filled out to be considered complete. Please complete both pages and return, by mail or fax, before registration, to:
Health Center, Lipscomb University,
One University Park Drive, Nashville, TN 37204-3951
Phone: 615.966.6304 Fax: 615.966.5286
Full Name
Social Security Number
Home Address
street
city
state
zip
Home Phone
Cell Phone
E-Mail
Date of Birth
o Female o Male Citizenship o USA o Other (please specify)
Name of Parent / Guardian / Spouse (please circle)
Phone
Address
street
city
state
zip
Relationship to Student
Emergency Contact Name & Number
Date you plan to enter by semester (please state year) Fall
Spring
Summer
Student Classification o Fr. o So. o Jr. o Sr. o Dietetic Intern o Student Pharmacist
Former LU student? o Yes o No Last term attended
Transfer? o Yes o No
MEDICAL HISTORY
o Allergy
o Dermatology
o Hearing/Sight
o Anemia
o Obesity
o High Blood Pressure
o Anorexia/Bulimia
o Seizure Disorder
o Mental Illness
o Diabetes
o Cardiac/Heart
o Gastrointestinal
o Immune Disorders
o Orthopedic
o Thyroid Problem
o Genitourinary
o Pulmonary/Lung
o Headaches/Migraine
o Anxiety/Depression
o Cancer
o Drug/Alcohol Problem
o Other
Please explain any item marked above (please attach extra sheet if additional space is needed)
Please provide allergies or sensitivities o none
List any current medications (including regularly taken over-the-counter medications, dietary supplements and herbs) o none
In order to ensure good health these assessments are suggested, but not required.
Cholesterol
Hct or Hgb
Blood Pressure
Height
Weight
HEALTH INSURANCE CARRIED ON LIPSCOMB STUDENT
Policy Number
Group Number
Name of Insured
Name of Insurance Company
Insurance Company’s Address
*If a student is under 18 years of age at the time of enrollment, please submit a Consent to Treat Minor Form as well
so that (s)he may be seen in the Health Center if needed for illness or injury.
(please see other side)
05.2011
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